Provider Demographics
NPI:1447222872
Name:POLING, JOHN M (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:POLING
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:2656 EAST SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401
Mailing Address - Country:US
Mailing Address - Phone:812-339-6131
Mailing Address - Fax:812-339-6161
Practice Address - Street 1:2656 EAST SECOND STREET
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401
Practice Address - Country:US
Practice Address - Phone:812-339-6131
Practice Address - Fax:812-339-6161
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1368152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U30905Medicare UPIN
IN955840Medicare PIN